Please Note: This is a high level summary of your benefits. Please see your certificate booklet for detailed benefits and exclusions.

Transcription

1 Insured and/or administered by: Cigna Health and Life Insurance Company University of Notre Dame du Lac Benefits at a Glance Policy #06946A Effective Date January 1, 2019 This plan provides minimum essential coverage. Please Note: This is a high level summary of your benefits. Please see your certificate booklet for detailed benefits and exclusions. Cigna Global Customer Service Universal Free Number (UIFN) Toll Free Telephone Number: Direct Telephone: Toll Free Fax Number: Direct Fax Number: Secure Website: Mail Delivery: Access Code + UIFN Toll-free number (collect calls accepted) Registration is required. (See member kit for registration information.) Secure available at this site. Cigna Global Health Benefits P.O. Box Wilmington, DE U.S.A. Cigna Global Health Benefits 300 Bellevue Parkway Wilmington, DE U.S.A Global Medical Plan U.S. In-Network U.S. Out-of-Network Eligibility Refer to eligibility definition in the certificate Lifetime Maximum Unlimited Calendar Year Deductible Per Individual $0 $400 $800 Per Family $0 $800 $1,600 Coinsurance 65% of the Maximum 85% (The percentage of covered expenses the plan pays) Reimbursable Charge Out-of-Pocket Maximum Per Individual $0 $1,950 $3,900 Per Family Includes Deductible Family members meet only their individual Out-of- Pocket and then their claims will be covered at ; if the family Out-of-Pocket has been met prior to their individual Out-of-Pocket being met, their claims will be paid at. $0 $4,600 $7,800 Accumulation Accumulation of Plan Deductible and Out-of-Pocket Maximums: Deductible and Out-of-Pocket Maximums will cross-accumulate between In-Network and Out-of-Network. All other plan maximums and service specific maximums (dollar and occurrence) will also cross-accumulate. Certification Requirements For services rendered inside the United States Precertification for inpatient and outpatient services received in the U.S. may be required. Providers must call our toll-free number, to pre-certify services. You or your dependents are responsible for ensuring that Out-of-Network providers pre-certify services. Failure to obtain precertification may affect Out-of-Pocket costs. This is a summary only and further details can be found in the certificate booklet. Page 1 of 6

2 Global Medical Plan U.S. In-Network U.S. Out-of-Network Physician s Services Physician s Office Visit $30 per office visit copay Surgery Performed In the Physician s Office $30 per office visit copay Allergy Treatment $30 per office visit copay Preventive Care Routine Preventive Care all ages Immunizations all ages Travel Immunizations (Immunizations as required for travel) Mammograms, PSA, PAP Smear and Colorectal Cancer Screenings ) ) ) ) ) ) Inpatient Hospital Facility Services Facility Physician Outpatient Facility Services Emergency Care (Refer to certificate for coverage and exclusions) (except if not a true emergency, then 65% after plan ) Urgent Care Services $30 per office visit copay $30 per office visit copay Laboratory and Radiology Services (including pre-admission testing) Physician s Office Visit Inpatient Facility Outpatient Facility Independent X-Ray and/ or Lab Facility Outpatient Short-Term Rehabilitation Therapy (Calendar Year Maximum: 60-days for all therapies combined) Includes: Cardiac and Pulmonary Rehab, Physical, Speech, Occupational and Cognitive Therapy $30 per office visit copay Physician s Office Outpatient Hospital Facility $30 per office visit copay Note: The Short-Term Rehabilitation Therapy maximum does not apply to the treatment of Autism and/or Mental Health conditions. Chiropractic Care Physician s Office Visit Calendar Year Maximum: 20 days not subject to plan Unlimited 20 days Page 2 of 6

3 Global Medical Plan Maternity Care Services Initial Visit to Confirm Pregnancy All subsequent Prenatal Visits, Postnatal Visits and Physician s Delivery Charges (i.e. global maternity fee) Physician s Office Visits in addition to the global maternity fee when performed by an OB/GYN or Specialist Delivery Facility (Inpatient Hospital, Birthing Center) Hearing Benefit One examination per 24 month period Hearing Aid Maximum Up to $1,500 per hearing aid unit necessary for each hearing impaired ear every 3 years for a dependent child under age 24 Mental Health and Substance Use Disorder Inpatient Facility Outpatient Office Visit U.S. In-Network $30 per office visit copay $30 per office visit copay $30 per office visit copay U.S. Out-of-Network Page 3 of 6

4 Prescription Drug Benefits Purchased outside the United States Purchased Inside the United States Only Benefit Highlights Non- Certain Preventive Care Medications covered under this plan and required as part of preventive care services (detailed information is available at )are payable at with no Copayment or Deductible, when purchased from a Pharmacy. A written prescription is required. You can look at Cigna s Prescription Drug List to see if your medication is covered, if it requires Prior Authorization or Step Therapy and which tier it falls under to determine what your copay or coinsurance will be. You can view Cigna s drug list on Select Performance 3 Tier from the drug list drop-down menu. Prior Authorizations Some medications on your drug list require prior authorization. This means you need to get approval from Cigna to have them covered under the pharmacy benefit plan. Step Therapy is required. It encourages you to try the most cost-effective and appropriate medications available first before more expensive medications are approved. Dispense as Written (DAW) you will pay the copay/coinsurance plus the difference in the cost between the brand name and generic medication unless your doctor requests the brand name medication. Prescription Drug Products at Retail Pharmacies Tier 1 Generic Drugs on the Prescription Drug List Tier 2 - Brand Drugs designated as preferred on the Prescription Drug List Tier 3 - Brand Drugs designated as non-preferred on the Prescription Drug List Prescription Drug Products at Retail Pharmacies consecutive 30-day supply at a No Charge after $5 copay No Charge after $30 copay No Charge after $45 copay consecutive 30-day supply at a non- 50% after plan 50% after plan 50% after plan non- Specialty Prescription Drug Products are limited to up to a consecutive 90-day supply per Prescription Order or Refill. Tier 1 Generic Drugs on the Prescription Drug List No Charge after $15 copay 50% after plan Tier 2 - Brand Drugs designated as preferred on the No Charge after $90 copay 50% after plan Prescription Drug List Tier 3 - Brand Drugs designated as non-preferred on the Prescription Drug List No Charge after $135 copay 50% after plan Prescription Drug Products at Home Delivery Pharmacies non- Specialty Prescription Drug Products are limited to up to a consecutive 90-day supply per Prescription Order or Refill. Tier 1 Generic Drugs on the Prescription Drug List No Charge after $15 copay In-Network coverage only Tier 2 - Brand Drugs designated as preferred on the No Charge after $90 copay In-Network coverage only Prescription Drug List Tier 3 - Brand Drugs designated as non-preferred on the Prescription Drug List No Charge after $135 copay In-Network coverage only Page 4 of 6

5 Global Vision Care Examinations One Eye Exam every 12 months Vision Hardware Lenses & Frames One pair of glasses or contact lenses every 12 months (Outside the U.S.) U.S. In-Network after plan Combined Maximum Benefit $200 U.S. Out-of-Network 65% after plan after plan Global Dental Care Calendar Year Maximum (for Class I, II, III) $1,500 Lifetime Maximum (for Class IV) $1,500 Calendar Year Deductible Class I Class II Class III Class IV Preventive Care For diagnostic and preventative services including: Oral Exam - 2 per person, per year Cleanings - 2 per person, per year Bitewing X-rays - 2 per person, per year Fluoride Applications - 1 per person, per year (Up to age 19) Sealants - 1 per tooth, per 3 years Full Mouth X-rays 1 per person, per 3 years Panoramic X-rays - 1 per person, per 3 years Basic Restorative For Basic Restorations: Endodontics Periodontics Prosthodontics Maintenance Oral Surgery Fillings Root Canal Periodontal Scaling and Root Planing Repair to Bridgework and Dentures Major Restorative For Major Restorations: Dentures Bridgework Crowns Orthodontia (Class IV Orthodontia applies only to a Dependent Child less than 19 years of age) $25 Individual / $75 Family not subject to plan 80% after plan 50% after plan 50% after plan, additionally there will be an Orthodontia separate of $50 Page 5 of 6

6 Emergency Evacuation Toll Free telephone number: Emergency Evacuation Family Travel Arrangements Return of Dependent Children of covered expenses not subject to the for services approved by Cigna. Economy round-trip airfare to the place of hospitalization for one family member for hospitalizations in excess of 7 days One-way economy airfare to return dependent children to their country of residence Repatriation of Mortal Remains coverage Page 6 of 6